Interview with Francesco Galassi (Julius Caesars Disease)

I am privileged to interview Dr. Francesco Galassi on behalf of UNRV. He and his co-author Hutan Ashrafian wrote the interesting and thought-provoking book, “Julius Caesar’s Disease: A new Diagnosis.”

Guy S. for UNRV: Dr. Galassi, how did you become interested in the study of paleopathology (the study of ancient diseases in man and animals)? More specifically, what inspired you to reevaluate the health of Julius Caesar?

Dr. Galassi: Ever since I was a child I have always been fascinated by ancient civilizations and languages. With a medical background, the possibility to combine different sources of information in order to investigate the historical presentation and evolutionary course of diseases through time is particularly captivating. Caesar has always been a historical character that captivated me because of his capacity to change the course of history through his lightning decisions and moves. My colleague and I noticed numerous discrepancies in his biographical accounts which led us to reinvestigate his symptoms and the likelihood of the traditional diagnosis of epilepsy. Our study, however, is not only about Caesar, namely one single “historical patient”, but it also opens a window on the role played by epilepsy in the past. It is said that so many great figures of antiquity suffered from it, yet, if closely inspected, one can clearly see that certain accounts, like those about Caesar, are contradictory and weak; in addition, epilepsy had clearly a double meaning in the ancient world. In a word, it was no ordinary disease.

If the scientist speaking now is allowed a personal note, I would like to say that I shall always be grateful to my coauthor Hutan for working with me on this, sharing his great knowledge and expertise. It was after the Caesar study that I became a full-time palaeopathologist.

UNRV: In your book, you and your co-author propose that Julius Caesar suffered from transient ischemic attacks (also known as TIAs or ministrokes). You suggest that both Julius Caesar and his adopted son Octavius attributed, instead, his symptoms of temporary physical weakness and mental confusion to epilepsy for political reasons. Why was epilepsy considered a “sacred disease” and where did this belief begin?

Dr. Galassi: The ancient sources are very clear: at the end of his life Caesar was weakened in his health and was patently suffering from a condition he could not hide. That’s why the sources report it. Thus, finding himself in the position of not being able to deny his physical decay, would it be preferable for him to admit to suffer from declining health, or, instead, from a disease, which was somehow linked to the divine sphere, epilepsy? Epilepsy was considered by the Greeks as a curse sent by the gods to punish man, that’s why it’s called “sacred”, namely it comes from the gods and the first to be affected by it was Hercules, a demi-god. However, other sources, primarily the pseudo-Aristotle clearly show how already in ancient times epilepsy was associated with genius-level mythological and historical figures and great accomplishments.

If the disease had just been a curse and a sign of social marginalization, then a mighty person constantly in the public eye would do anything in his power to get rid of or conceal this stigma. One might object that Caesar didn’t have the time to do that, since he was prematurely assassinated, but his successor Augustus was in power (and we are talking of a dyspotic regime in which any form of opposition was crushed and many of the historians of that time were ruthlessly censored) for a very long period of time. On the one hand he elevates his adoptive father to the rank of god, the almighty father and patron of the ruling Julian dynasty, but on the other hand he does nothing to eliminate any traces of a disease considered to be a curse sent by the gods. It makes no sense at all. Let me add one additional aspect. Hippocrates argued that the “sacred disease” was an ordinary, organic disease, it was by no means special.

This proves that in ancient Greece a rational approach to the matter already existed in some primitive form. Nonetheless, we clearly realize that this observation did not enjoy much success and the aura of myth surrounding this pathology continued to exist at popular level (later in the Middle Ages it would be linked to madness and demonic possession). While the Roman elite might well have been skeptic and agnostic – certainly critical towards the belief in divine signs – certainly the crowds were not and the power of omen could easily be implemented as a political weapon. A “wonderful weapon” as Hutan and I called it. And Caesar was able to make marvellous use of divine signs for his political agenda.

UNRV: Part of the differential diagnosis for Caesar’s poor health included tertiary syphilis, which you excluded. In the modern pre-penicillin era, tertiary syphilis was a frequent cause of neurologic and cardiovascular complications. In the book, you state that syphilis in ancient Rome possibly did not exist and certainly was not widespread. Do you believe, therefore, that syphilis (at least the virulent form we know today) was probably brought to Europe after the time of Columbus from the Americas?

Dr. Galassi: Specifically addressing Caesar’s case, we can exclude syphilis, since the sources rather point in the direction of a way more common condition of a cardiovascular nature. The palaeopathological consensus it that syphilis did not exist in Europe before Columbus’s voyages. Some skeletons have been found to show lesions which may be suggestive of syphilis, however the morphological evidence alone appears not be strong enough to support this stance, since certain lesions are produced by other diseases, too. I really hope that one day the fast-developing palaeo-molecular technologies will be able to assess this on such ancient human remains so that a definitive answer may be given. One way or the other, that would represent a remarkable research goal.

UNRV: Are there any ancient sources that give an accurate clinical description of common modern ailments such as high blood pressure, diabetes, cardiovascular and cerebrovascular disease, or cancer?

Dr. Galassi: The ancient authors describe the diseases you mention, particularly diabetes and cardiovascular disease with a reasonably good degree of accuracy. Those sources represented the main source of information for centuries. In the past 100 years many more details and data have been collected through the scientific study of mummies. Let me just give you a straightforward example. Until some decades ago, people would be of the opinion that atherosclerosis was the result of modern life-style, that is a product of modern civilization. Palaeopathological research, instead, has clearly demonstrated the antiquity of cardiovascular diseases and atherosclerotic changes in arteries, particularly in the upper classes of ancient civilisations.

UNRV: Many people feel that the role of disease and illness in shaping ancient history is inadequately investigated. Would you agree?

Dr. Galassi: Diseases do shape history, as much as history shapes diseases. In the pre-vaccination era, tetanus would kill lots of people (e.g. children or soldiers wounded in battle). Scientific progresses made tetanus decrease considerably in the modern world. Attributing major historical events or transitions to disease alone, would be a mistake, since that would mean biologising history. Historical processes instead show much more sophisticated dynamics and are influenced by a definitely longer list of factors. At the same time, I would agree with those who are of the opinion that we should focus more on the relative impact of diseases on our history. Personally I wouldn’t blame this lack on current historiographical research priorities nor on anybody in particular. You see, diseases and their interaction with human populations are highly complicated processes that require a multi-disciplinary and multi-level approach in the world we live in.

Imagine when we try to figure out how disease presented in the past, simply relying on scant sources (literary or material). In palaeopathology an even higher level of coordination and collaboration between specialists from the most heterogenous fields is not only required but warmheartedly encouraged. Words change in their meaning over time, therefore we need philologists to crack their meaning for the specific historical period we are analyzing. Just think of “gout”: thanks to the important discoveries by Sir Alfred Garrod (1819-1907) we now know that this rheumatological condition is caused by a precipitation of a substance called uric acid in the joints when its blood concentration is higher than a certain level. In the 15th or 16th century, for instance, gout was a much more general term encompassing all sorts of rheumatic afflictions, most of which would only be described and classified much later. That’s why we need a strong and virtuous alliance between humanities specialists and science ones. I feel there is tremendous potential for joint work and indeed the best days for multidisciplinary approaches lie ahead.

UNRV: From the Vindolanda tablets we can learn a lot about everyday life at the Roman frontier of Hadrian’s Wall. From one tablet (# 154) we learn about the readiness and health of the First Cohort of Tungrians. Of the 31 soldiers who were present but unable to perform duties (more than 10% of the total Cohort), ten were suffering from eye inflammation. Were eye ailments common among legionaries and what was the etiology of this eye inflammation? (Possible reasons suggested for the eye inflammation have included trachoma infection, malnutrition, and even environmental irritants such as dust from marching.)

Dr. Galassi: You must be alluding to the famous writing-table where the word “lippientes” can somehow still be read. Lippi were those people suffering from eye-infections of different sorts, often not too serious afflictions since they were clearly distinguished from aegri (the sick) and from the volnerati (the wounded).The etiologies you mention are indeed correct. In the number of known ophthalmological diseases we recall cysts, stye, blepharitis, conjunctivitis, lacrimal fistula. All these diseases are described in the works of Celsus and Galen. Another condition worthy of mention was epiphora, a form of incessant lacrimation mostly caused by an obstruction of the nasolacrimal ducts. I am currently investigating this disease in depth.

UNRV: Recent DNA analysis of skeletal remains from the Plague of Justinian (541-542 AD) confirm the theory that the plague was caused by Yersinia pestis bacterium (the cause of bubonic plague and the infamous Black Death that devastated Europe in the 14th century). The cause of plagues that devastated ancient Rome are still debated, however. The cause is unknown for the Antonine Plague (also known as Plague of Galen) that disrupted the Roman Empire from 165-180 AD during the time of Marcus Aurelius Antoninus. Similarly, the cause for the Plague of Cyprian in the third century is still controversial. Do you have any thoughts about possible infectious etiologies for these two plagues?

Dr. Galassi: Unlike for the Plague of Justinian, no definitive palaeomolecular results have been yielded on the Antonine or Cyprian’s. Historians have proposed smallpox and/or measles. Smallpox may be plausible yet – as correctly pointed out by Sabbatani and Fiorino in 2009 (https://www.ncbi.nlm.nih.gov/pubmed/20046111) - Galen, who witnessed the disease, never specifically mentioned in recovered patients the typical indelible scars which very often disfigure their faces. Sadly, in order to recover ancient DNA of Variola virus (if we assume that smallpox was the disease in question) mummified bodies with their still preserved soft tissues (including skin lesions) are definitely better, which have not been preserved – to the best of our knowledge – for the two Plagues you mention. Osteological remains, instead, may not be equally good material for this purpose. For Cyprian’s plague even haemorrhagic fevers have been postulated, yet it must be acknowledged that the original sources are not clear enough to allow us to formulate a confident retrospective diagnosis. Future molecular analyses might elucidate the whole matter further. It is preferable to wait and keep collecting data.

UNRV: What do you see for the future role of DNA and genomic studies in the research of ancient history? In what settings could these studies be used?

Dr. Galassi: Palaeomolecular analysis represents the highest technological form of palaeopathological research available these days. It’s yielding fascinating results which allows us to understand our past and evolution. We can not only clarify the etiology of past epidemics but also reconstruct the full genome of pathogens which have devastated civilizations and peoples through history. We also learn a lot about genes which predispose to the development of complex multifactorial diseases such as the cardiovascular ones. I always remark that it is, however, always important try to combine as much information as possible, from different sources. This allows researchers to reconstruct ancient phenotypes and genotypes, thus we a have a full clinical picture from a bygone age.

UNRV: Dr. Galassi, as someone in the medical field, how has your study of ancient medical history impacted on your own perspective on the care of patients and modern medicine?

Dr. Galassi: Palaeopathology and medical history can teach us two fundamental lessons. The first is that we should not feel overly satisfied with the knowledge that we possess today, yet we should study the matter in depth, investigate the antiquity and, above all, understand the evolutionary patterns at the heart of pathologies still affecting us nowadays. The second is that whenever we take care of a patient we should not only think of this person in terms of the disease he or she is suffering from nor should we only rely on the most recent technological advances. Each patient is first of a human being who deserves the greatest consideration and respect and his/her medical history must be assessed and examined in depth, in order to understand it properly and provide the best possible diagnosis and subsequent therapeutical strategy. Paleopathology and history of medicine teach researchers to cultivate their ability to spot the tiniest details and to analyse complex items both microscopically and macroscopically, combining different approaches and methodologies.

UNRV: Dr. Galassi, thank you for your time. I hope you will join us at UNRV for further discussions about ancient Roman history and share your expertise on medical topics of the ancient world.

• ...more Book Reviews!
• Caesar's Disease: A New Diagnosis by Galassi and Ashrafian
• Rubicon by Tom Holland
• The Roman Soldier by G. R. Watson

Francesco Maria Galassi, MD, is a paleopathologist at Zurich University’s Institute of Evolutionary Medicine, where he serves as Assistant and Principal Investigator of the Italian Paleopathology Project. He graduated from the University of Bologna and has collected research experiences at the University of Oxford and Imperial College London. Besides studying osteological remains and mummies, he specialises in the analysis of ancient texts in order to identify the historical presentation and evolution of diseases throughout history. Amongst his most acclaimed studies, the causes of death of Alaric I and Giovanni Boccaccio. Aged only 27, Francesco Galassi is one of the youngest palaeopathologists in the world and already an expert in the field of palaeomedicine. Francesco’s studies have received worldwide attention in quality papers such Forbes Magazine, The Guardian, The Telegraph and he regularly features in the press and radio-TV programs as commentator of paleopathological research.

Hutan Ashrafian, BSc Hons, MBBS, MBA, PhD, MRCS is a surgeon, historian, systems biologist, biostatistician, paleopathologist and philosopher. He is currently lecturer in surgery at Imperial College London and surgeon registrar at Chelsea and Westminster Hospital in London. His historical and paleopathological work spans the era of Alexander the Great and the classical world, epistemology and the earliest world literature from the Ancient Near East, art and science in the renaissance focusing on the work of Leonardo da Vinci. As an Egyptologist, he has offered the first pathological analysis of the Great Sphinx and his analysis of the death of Tutankhamun was featured in documentaries on the BBC and the Smithsonian Channel. He is the founding president of the Institute of Polymaths.

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Interview with Dr. Francesco Galassi on Julius Caesars Disease: A New Diagnosis - Related Topic: Ides of March

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